COSA Survey Distribution Application Form
To be completed by the applicant when submitting a request to COSA /

This application form should be completed and submitted after referring to the COSA Survey Policy

Checklist of documents to be provided to support your application:

☐A written submission of the research project, its aims, and projected outcomes

☐Evidence of ethical approval (applications can be made prior to ethical approval; however surveys will not be distributed until ethical approval has been given)

☐Copies of all approved survey or questionnaire material

☐Copies of all communications to be sent including covering emails, participant information statements and one reminder communication (if required)

Study Title: Click here to enter text.

Application submitted by: Click here to enter text.

Guiding principles for COSA activities:

  1. COSA activities should have a multidisciplinary focus
  2. COSA activities should have a clinical focus
  3. COSA activities should have outcomes relevant to its members, patients and carers
  4. COSA will act as a hub and facilitator for idea generation

Please provide a statement addressing how this survey aligns with COSA’s mission and cancer.

Click here to enter text.

When is the survey expected to be distributed? Click here to enter a date.

Please include any comments about the timing of survey distribution you may wish to share with the COSA Survey Review Committee, including any reminders to be sent:

Click here to enter text.

Are the all documents submitted the final documents?

☐ Yes

☐ No(If No, please indicate what is not finalised. This may affect the decision of the COSA Survey Review Committee)

Click here to enter text.

How will you report your results back to the survey participants?

Click here to enter text.

Who within the COSA membership would you like to complete this survey?

Please note: surveys are only distributed to members who have elected to receive electronic communication from COSA

☐ All COSA members

OR please select which COSA Group(s) you survey should be distributed to:

☐ Adolescent & Young Adult / ☐ Biobanking
☐ Breast Cancer / ☐ Cancer Biology
☐ Cancer Care Coordination / ☐ Cancer Pharmacists
☐ Clinical Trials Research Professionals / ☐ Complementary & Integrative Therapies
☐ Developing Nations / ☐ Epidemiology
☐ Exercise & Cancer / ☐ Familial Cancer
☐ Gastrointestinal Cancer / ☐ Geriatric Oncology
☐ Gynaecological Cancer / ☐ Lung Cancer
☐ Melanoma & Skin Cancer / ☐ Neuroendocrine Tumours
☐ Neuro-Oncology / ☐ Nutrition
☐ Paediatric Oncology / ☐ Palliative Care
☐ Psycho-Oncology / ☐ Radiation Oncology
☐ Rare Cancers / ☐ Regional & Rural Oncology
☐ Surgical Oncology / ☐ Survivorship
☐ Urologic Oncology

OR please select the profession(s) you wish to distribute the survey to:

☐ Administration/Management / ☐ Advanced Trainee / ☐ Clinical Research Professional
☐ Geneticist / ☐ Educator/Academic / ☐ Medical Oncologist
☐ Nurse / ☐ Nutritionist/Dietician / ☐ Palliative Care Physician
☐ Pharmacist / ☐ Psycho-Oncologist / ☐ Radiation Oncologist
☐ Radiation Therapist / ☐ Social Worker / ☐ Surgeon

Has this survey been submitted for distribution with any other organisation?

☐ Yes (If yes, fill in the table below)☐ No

Organisation(s) / Status of request / Does their distribution list overlap with COSA membership? / How will you deal with duplicate participants across the organisations?*

*This will be taken into consideration when assessing the burden on COSA members

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